10/21/2013 1 Management of Chronic Problems in Otolaryngology Steven D. Pletcher Associate Professor Department of Otolaryngology – Head and NecK Surgery University of California, San Francisco Disclosures Patent Pending 61/624, 105 - Sinus diagnostics and therapeutics Consultant, BioInspire Inc Otolaryngology – Head and Neck Surgery Specialty formerly known as ENT Early Nights and Tennis Easy, Not Tough Case-based review of common and uncommon problems in our field Ear Hearing Loss
This document is posted to help you gain knowledge. Please leave a comment to let me know what you think about it! Share it to your friends and learn new things together.
Transcript
10/21/2013
1
Management of Chronic Problems in Otolaryngology
Steven D. PletcherAssociate Professor
Department of Otolaryngology –Head and NecK Surgery
University of California, San Francisco
Disclosures
Patent Pending 61/624, 105 - Sinus diagnostics and therapeutics
Consultant, BioInspire Inc
Otolaryngology – Head and Neck Surgery
Specialty formerly known as ENT Early Nights and Tennis Easy, Not Tough
Case-based review of common and uncommon problems in our field
Ear
Hearing Loss
10/21/2013
2
Case #1 72 y/o woman with hearing loss and
tinnitus Otologic History
No vertigo, otalgia, or otorrhea No history of prior surgery or frequent
infections + history of hearing loss in family (father
and grandfather) Went to “Rock concerts” in the sixties
Case #1
PMH: none Meds: none Exam
Vth and VIIth nerves normal Normal appearance of tympanic membrane
Case #1
Tuning fork tests (512 Hz) Weber: Midline Rinne: Air conduction > Bone Conduction
Bilaterally
Weber & Rinne Tests
10/21/2013
3
Audiogram Diagnosis
Presbycusis Treatment
Consideration of Hearing Aids Listening strategies and assistive devices Avoidance of noise exposure
New Frontiers? Implantable hearing aids Cochlear Implants “partial insertion”
Case #2
Hearing Loss
Case #2 36 y/o woman with hearing loss and
tinnitus Symptoms worse on right side
Otologic History No vertigo, otalgia, or otorrhea No prior ear surgery No history of ear infections + family history of hearing loss (mother in
late 20’s) No history of noise exposure
10/21/2013
4
Case #2
PMH: recently delivered first child Meds: none Exam
Vth and VIIth nerves normal Normal appearance of tympanic membrane
Case #2 Tuning fork tests (512 Hz)
Weber: To the Right Rinne
Bone conduction > Air conduction bilaterally
Audiogram Most Likely Diagnosis?
Meniere’s disease Otosclerosis Otitis Media with Effusion Cholesteatoma Acoustic Neuroma
10/21/2013
5
Diagnosis Otosclerosis
Disease of abnormal bone remodeling within the middle/inner ear
Most patients present with unilateral conductive hearing loss and normal TM examination More severe cases may be bilateral with associated
sensorineural hearing loss
Conductive loss due to fixation of the Stapes footplate within the Oval Window
Ear Picture
Otosclerosis
Patients often have a family history of hearing loss
In women, symptoms may worsen during pregnancy
Otosclerosis
Treatment Hearing Aid Surgery (Stapedectomy/Stapedotomy)
10/21/2013
6
Stapes Surgery
Popularized by Dr. John Shea in the 1956 Revolutionized treatment of otosclerosis
Stapes bone partially removed Prosthesis inserted and linked to incus
Stapes Surgery
Results 90% with complete or near complete
correction of conductive component of hearing loss
9% with no change in hearing 1% with complete sensorineural loss
10/21/2013
7
Audiogram Post-op Audiogram
Post-op Audiogram
Case #3
Hearing Loss
10/21/2013
8
Case #3 60 y/o woman with right-sided hearing
loss and vertigo Balance symptoms worse with loud noises
Otologic History No tinnitus, otalgia, or otorrhea No history of prior surgery or frequent
infections No history of hearing loss in family
Case #3
PMH: none Meds: none Exam
Vth and VIIth nerves normal Normal appearance of tympanic membrane
Case #3
Tuning fork tests (512 Hz) Weber Midline Rinne Air conduction > Bone Conduction
Bilaterally
Audiogram
10/21/2013
9
Next Step In Evaluation/Treatment?
Hearing Aid evaluation/referral CT scan of the brain/temporal bone Stapedectomy Cochlear implantation MRI of the brain/temporal bone
Diagnosis
Vertigo & conductive hearing loss Concern for Superior Canal Dehiscence
Syndrome
Plan CT Temporal Bone Vestibular Evoked Myogenic Potential (VEMP)
testing
CT Superior Canal Dehiscence
Syndrome described by Lloyd Minor in 1998
Loss of bone over the superior vestibular canal Creates a “3rd mobile window”
Noise and pressure-induced vertigo and hearing loss
Oral cavity WNL Oropharynx: prominent, firm left tonsil No cervical adenopathy
10/21/2013
18
MRI Biopsy
Squamous Cell Carcinoma
Oropharyngeal SCC
Which of the following is the most relevant risk factor for developing oropharyngeal SCC? Smoking history EtOH abuse Smokeless tobacco use Number of sexual partners History of prior radiation
HPV Associated SCC of the Oropharynx
Epidemiology Vaccines Vaccine recommendations Pap smear of the tonsils? Treatment De-escalation
D’Souza et al. Prev Med 2011 Oct;53 Suppl 1:S5-S11. doi
Fakhry et al. Cancer Prev Res 2011 Sep;4(9):1378-84.